Good Faith Estimate

If you have not had an initial diagnostic session yet, your provider will evaluate you over the course of your first few sessions and provide a diagnosis that matches your presenting symptoms as part of your treatment plan. If you are a current client and this is an updated Good Faith Estimate for continued care, you have a diagnosis on file that you may discuss with your provider at any time.

You may choose to decline receiving a formal mental health diagnosis. However, insurance companies generally require a diagnosis before they will process or reimburse claims. If you decline receiving a diagnosis, you will be responsible for all applicable service fees.

• Provider / facility: Juniper Ridge Therapy PLLC
• Provider: Sarah Mohanavilasam, LCSW, LCSW #13989909-3501
• Provider / facility NPI: 1780510784
• Service location: 515 South 700 East, Suite 2F, Salt Lake City, UT 84102 and/or via telehealth services
• Telehealth services are provided only to clients located within the state of Utah.

The following is a list of potential charges for psychotherapy services that are currently scheduled, or that you may choose to later schedule. For this Good Faith Estimate, total estimated costs are calculated on an annualized basis and assume one intake/evaluation appointment and one weekly appointment (individual or couples/family) for one year.

If you attend sessions less frequently than weekly, your total estimated costs will be lower. If you receive this estimate partway through a calendar year, the total still shows what a full year would cost.

Diagnosis code(s) (ICD-10):To be determined following the initial diagnostic evaluation, or as documented in the client's clinical record for clients already in care.

• Intake / Evaluation (90791): $200 × 1 — estimated annual cost: $200
• Psychotherapy Sessions (90837, 90846, 90847): $150 × 51 — estimated annual cost: $7,650

Psychotherapy services may include individual therapy, parent-only sessions, family therapy, or a combination of these services depending on the clinical needs of the identified client. The frequency and type of services may change over the course of treatment, and only services actually provided will be billed.

Other charges described in the Practice's Consent for Services & Practice Policies—including late-cancellation, missed-appointment, after-hours or crisis contact, records and coordination-of-care time, and legal-related activities—are not included in the total above. These administrative or non-scheduled fees apply only if you incur them.

Questions about this estimate? Email billing@juniperridgetherapy.com.

If you do not have insurance or voluntarily choose not to use your insurance for services, you are considered a self-pay client. As a self-pay client, you are fully responsible for all fees for services you receive. If you have been granted a reduced self-pay rate, your estimated total costs will be lower than those identified above.

If the practice submits claims to your insurance, we bill at the rates stated above for standard services and at our standard market rates for other services not anticipated here. Your insurance—not the Practice—determines how much of each billable service you must pay. All insurance plans require a formal diagnosis to process claims; if you decline to have a diagnosis in your file, you will be responsible for all service fees. Late-arrival, late-cancel, and no-show fees are not covered by insurance and are your responsibility.

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your care, based on information known at the time it was created. It does not include unknown or unexpected costs that may arise during treatment.

You could be charged more if emergency or special circumstances occur, if you increase the frequency or length of services, if you use additional health-care services, or for other unanticipated services outside the standard services listed above. This estimate also does not include auxiliary (non-health-care) products and services you may voluntarily choose to use.

You have the right to request and receive an estimate of costs for potential health-care-related items and services. This Good Faith Estimate shows the costs reasonably expected for your health-care needs over a specified amount of time.

You may contact your provider or their billing office to explain that the billed charges are at least $400 higher than your Good Faith Estimate. You can ask them to update the bill to match the estimate, negotiate the bill, or ask whether financial assistance is available.

You may also start a dispute-resolution process with the U.S. Department of Health and Human Services (HHS). You must start it within 120 calendar days (about four months) of the date on the original bill. HHS charges a $25 fee. If the reviewing agency agrees with you, you will pay the price on this estimate; if it agrees with the provider, you will pay the higher amount.

For more information, visit cms.gov/nosurprises or call 1-800-985-3059. Save a copy or a picture of your Good Faith Estimate. A copy will also be maintained in your clinical record.

By signing the Good Faith Estimate provided to you, you acknowledge that you have read and understand it, including the current total estimated fees; your insurance carrier, not the Practice, determines your out-of-pocket costs; out-of-network care may cost you more; the estimate is not a contract and does not obligate you to accept any listed service; and you are responsible for contracted amounts your insurance does not pay.